Let’s talk about the perineum! (Yeah, high-five if you’ve got one – okay, it’s no secret everyone has one.) It’s a big concern among expectant moms, will my perineum make it out alive?

Sometimes in my childbirth classes I can literally see a huge floating question mark sitting on the tops of women’s heads. Like a thought bubble pleading silently, “Can you talk about vaginas, now!? Will mine ever look the same!? Will I be normal after birth? What will happen to my perineum during childbirth?”

Well, before we answer those questions we need to understand some of the sensations women may experience during childbirth and what we can do to protect the perineum through it all.

Alright, let’s dive right in, shall we? First let’s examine the vagina, or rather the vulva, and talk about the perineum and what happens towards the end of labor:

The perineum is the skin between the vagina and the anus, which thins out and stretches over the baby’s presenting part (usually the head) as it is born. (Source) During second stage (pushing) the perineum plays an especially vital role in the birth of the baby.

Okay, let’s talk about what’s going on down there as we approach second stage!

(“Down there” and “bottom” are lite and easy words that I use to describe the vagina, vaginal opening, vulva, perineum and rectum. These are the words my midwife used with me and I will use them with you! Okidoki?)

Building Pressure:

As baby descends and engages and labor deeply progresses, a woman will experience increasing pressure in her bottom as her pelvic passage begins to stretch open. Often, the stimulation sends a signal to a laboring mother’s brain that she needs to have a bowel movement. And sometimes that’s exactly what a laboring mother may do.

I’ve worked with a lot of moms who, while in the thick of labor, look up at me with urgency and quickly move to the bathroom. Baby’s decent stimulated her bowels. On occasion the laboring mother may have a genuine need to go (this is nature’s lovely way of making sure that doesn’t happen during second stage), or other times the mom may simply relax on the toilet, letting her muscles soften till she becomes more comfortable with these new sensations. Either response is totally normal.

Keep in mind, the pressure felt during birth is sometimes really alarming, because, let’s be honest here, we’ve spent our whole life learning to be discrete about the urge to poop. But in the case of childbirth (and possibly a few other occasions!) this sensation is cause for celebration, it tells us baby is descending and the mother is moving closer towards holding her baby in her arms.

Grunting:

Often at this stage in labor, you’ll begin to hear mothers grunt at the peak of their contractions. Imagine, mom is moaning through her contraction and suddenly her breathy bellowing goes like this, “ooooooooooooooh, oooooooooooooooooh, ooooo uh, uh, uh, uh, uhr, uhr, uhr, oooooooooh, oooooooh, oooooh”

Aha! That’s a great sound! Those short little grunty noises that mom just made in the middle of her contraction signal that her body is beginning to involuntarily push at the peak of her rush.

As baby descends, increasing pressure is felt in the bottom and the rectum is stimulated.

Supportive Hands:

You’ll also sometimes see, as a laboring mother begins to feel that all-consuming pressure, that she will place her hands right on her bottom, cupping her groin and supporting her vulva. That’s wonderful and absolutely normal! Besides for giving her bottom additional support during this stage, it also allows the laboring mother to stay more in touch and in control of her body’s response to labor. What’s not to love!?

Pressure, grunting, and supportive hands are clear signs that birth is progressing…

Does that mean it’s time to push yet? No, not necessarily. It only means what she’s telling us from her body language: her bottom is feeling pressure, things are being stimulated, baby is descending and birth is progressing normally.

Enjoy, Accept, Relax

At this transitional stage between first and second stage of labor, it’s ideal for mom to not add additional force (just yet!) as she begins to feel those early urges to push. As her uterus contracts, the bands of muscle thicken at the top of the fundus and begin to push down on their own, expelling baby further into the birth canal, this is the beginning of what will soon become a very strong urge to push.

It’s a good idea at this cross-road in labor to encourage mom to enjoy knowing just how well her body is working, accept the intensity of the change in sensations she’s feeling, and relax into her rushes a little more fully. This provides mom with an opportunity to wrap her brain around the idea of what the pushing urge feels like before diving right into it.

Powerful Pressure | Second Stage | Pushing

As labor thickens into heavy travail (an old Biblical word that I feel really adequately describes transitional labor) the intensity of pressure a woman begins to feel increases exponentially.

Baby’s head is now stretching the vaginal and pelvic floor muscles. Receptors in these tissues trigger involuntary pushing, and signal more oxytocin to the body – a complex hormone which stimulates contractions. (Source) A woman will now begin to feel the urge to push through almost the entirety of her contraction and not just the peak of it.

Mom will need reassurance at this point that she is okay, she needs to know that the pressure she feels is normal, and that even if she’s absolutely convinced she will birth her baby out of her butt, she will not. (Yeah, I said it.)

The intensity of the pressure is admittedly scary, but it’s also needed in order to bring forth baby into the world. And while it’s like nothing any first-time mother will have felt before, and can be utterly overwhelming, it is still very normal in terms of childbirth and not to be feared.

This is a doorway in labor that mothers walk through, there is no way around this passage of birth intensity, only through it. It is time to push!

Please note, while these illustrations are fantastic, the information on step four regarding suctioning a baby is now contraindicated and outdated. Evidence now states that unless baby is unresponsive, suctioning is not necessary. Source: //www.ncbi.nlm.nih.gov/pmc/articles/PMC2666857/

Two Steps Forward, One Step Back

As mom pushes her baby down and out in that wonderful “J” shape of pushing, we’ll often see a little two-step dance, baby descends during the contraction, pressing on the perineum and the perineum begins to bulge and expand, and after the contraction ends, baby moves up and the perineum softens and relaxes. This happens over and over again.

This is a process my own midwives and mentors taught me to refer to as “two steps forward, one step back.” This dance is very important for the integrity of the perineum. It allows the skin to stretch slowly and gently, giving the perineum time to accommodate the baby’s head without tearing.

Ring of Fire

Once the head of the baby has firmly ducked under the pelvic bone, crowning will begin to take place. We use the term “crowning” to describe how the vaginal opening and vulva stretches around baby’s head looking like a crown.

As baby crowns, the labia and perineum begin to expand and bulge, this point is often referred to as the “ring of fire.” There is a lot of stinging and burning accompanied with the ring of fire, fortunately, it doesn’t last for too long, although we shouldn’t rush through it. This stinging sensation sends a message to the woman’s body to hold off on pushing. (Source)

(On a side note, sometimes as an exercise to describe the ring of fire to my students, I’ll ask them to stretch open the sides of their mouth with their fingers. I find this gives a good sense of the type of stinging that’s felt in birth. As a bonus, everyone looking ridiculous together usually gets us all laughing, which is always good when talking about crowning!)

During crowning it’s good for the laboring mother to stop adding additional force to her body’s own urge to push. Instead she should breathe out her baby and allow her body to do the work on its own. (This is something she has already practiced in birth during the transitional stage mentioned above. See, it all comes together now!)

You see, after the baby’s head is through the pelvis, only the tender perineal tissues are holding baby in (Source), and the mother needs to be mindful of not pushing too forcefully in order to protect this area of a her body.

How does she do that? She breathes her baby out…

Breathing Baby Out

Gentle, easy breaths that resemble panting allow the baby’s head to emerge slowly and tenderly, helping to keep the perineum intact. Actually, for many mothers breathing out her baby is an innate response to the ring of fire.

Think about it: a base response to pain, for all ages, are quick short breaths. I see my children do this all the time. A little high-pitched panting expression that happens when they’ve smashed their finger or stubbed their little toe.

Likewise, when mothers are left to labor without heavy coaching, at the point of crowning, you’ll sometimes see this panting and high-pitched breathing technique occur. (Watch some birth videos, and listen for that quick high-pitched breathy howl at crowning, and then you’ll start to see it all the time.)

Supporting The Perineum

Also, a mother’s hands may instinctively reach down again and apply pressure to her own perineum. Although, I should mention it’s quite common that you’ll see the midwife or OB apply slight counter pressure to a woman’s perineum at this stage too. Also, some care providers will apply a warm compress or olive oil to a mother’s perineum to assist in preventing tears.

Once the baby’s head has fully crowned, it will only be another couple of pushes before baby is born. After the birth of the baby’s head, baby’s shoulders are delivered, and the rest of the baby’s body pours out from its mother shortly after.

It’s miraculous to see and testifies to the function and beauty of the female body.Women’s bodies are just amazing, y’all!

Image source unknown

There are a lot of things a woman can do that will increase her chances of having an intact perineum, here are a few of my tips, please note this list is not exhaustive or comprehensive:

A mother should avoid birthing on her back, but rather birth on her side, in an upright position, or on her hands and knees.

Warm compresses (not hot!) on the perineum during labor.

Avoid power pushing. Power pushing, or what is known as purple pushing, is when a woman holds her breath for long periods of time and pushes beyond what feels comfortable or natural to her body. This type of pushing increases a woman’s chance of tearing.

Avoid widely flexed legs. Knees should be pointing forward and not to the sides. Source | Source

Follow her own body’s cues during crowning and slow down her pushing.

Use a mirror, if she’s comfortable with that. Seeing what’s happening during second stage can help the mother connect to her body, and allow her to direct her body’s urges better.

The laboring mother should move to positions that are most comfortable for her during second stage. For example, the mother could say, “Before my next contraction starts, I would like to turn to my left side. Would you help me do this, please?”

Hire a doula! A doula reduces a woman’s need for an epidural and for forceps delivery, both of which increase the laboring mother’s odds of perineal damage.

The mother should find a care provider who supports birthing in ways which allow for an intact perineum.

wonderful! I had always wanted to breath out a baby but it seems my body has other plans :) Once my body begins to push on its on all bets are off and baby flies out. Last one was almost born on the toilet.
i wish every pregnant woman could read this. so much amazing information

Reblogged this on Maggie Marie and commented:
I might be in love with this woman, what a great website. These are some good tips about the perineum. I especially like the tip on “power pushing”, it is in line with my experience and observation.

This article is amazing! I learned so much clicking on the links and reading the birthing stories. It was shocking to read that kegels are more detrimental than helpful but after reading the full article it makes complete sense! I am just entering my second trimester and I am going to make sure to do squats at least a few times a day. Thank you for taking the time to create this article!

With my two sons I (as quoted by my midwife) “had an odd tear”. I tore up inbetween the clitoris and urethra. Do these strategies help out with non-perineum tears? Also, since I have torn in the same place 2 times already, is there a chance to not tear again with future babies?

I screamed through my pushing stage. They told me I only pushed for 8 minutes and I still can’t believe it. The pressure and pain were more intense than I expected and yelling definitely helped.
If you haven’t already you should do a post about what to expect down there after it all. I was sore for a long time. Recovery was worse thaan expected. And sex scared me to death (which of course made things worse) because I got a scary sensation that things weren’t stretching out and I was going to tear. I was sure my doc had stitched me up too far or something. He didn’t, but that feeling lasted months before being normal again.

I screamed as I pushed my first baby out because I thought forcing ‘out’ would help me push through the pain. As I prepared for the birth of my second I learned that screaming tenses all the muscles and tissue down there and increases the possibility of tearing. The article I read that in “The Pink Kit” had an excercise where you put your finger in there and scream, then do a low moan, and see how much it tightens with the scream, in comparison to actually relaxing when you do low pitched moans.

Reblogged this on A Beautiful Creation Doula and commented:
Ask any woman what their biggest fears about childbirth are and inevitably the word “tearing” comes up. This blog has excellent information about the perineum and how to protect it! Enjoy!

Great article, so glad to see this being talked about, I think its often shied away from.

My only feedback would be that I was sad to see a naked freshly waxed vulva in the first anatomy diagram, ie presented as the norm. I think seeing a vulva in its natural adult state would be more empowering, and to reinforce the fact that women don’t HAVE to do any grooming they wouldn’t normally do for the birth, just be your usual lovely state whether that’s free and bushy, neatly trimmed or smooth and bare.

Also don’t forget about perineal massage! Super empowering and encourages women to learn how to relax their pelvic floor.

Great article. I just have one concern….you mention standing and squatting as good labouring positions to help protect perineum…have you got any evidence for this? Only I’ve read that these positions are actually very bad for preventing tears as put far too much pressure on perineum (gravity + contraction). I’d be interested to read anything that suggests the contrary though x

I loved this article… The place from where you share all this intelligent information is beautiful… thank you so much… from a granmama who encourages all women to love and appreciate their physical bodies…

Awesome! So much information here that every pregnant woman, or those planning to get pregnant should read. (just hope they wont get scared though :-)). I thought I know so much because my doctor taught me well. But there really are some things that they will surely miss. You got those covered here. Keep it up with compiling information like this please. I am sure it will help so many women out there.

I wish I had someone like you with me for my past two deliveries which were so traumatic and frightening ending in forceps spinal blocks and tears. It’s taken me 16 yrs to let myself get pregnant again and I’m so terrified of it all still. I felt out of control and nuisance patient in the hospital. I’ve 7 months to go and wish I hadn’t got to go through it again

Very nervous about the big day, was sure I wanted epidural to get through it, this article has made me feel a lot calmer about it , currently looking for a doula and will be sure to take oil with me :-/

Nice to read this. My doctor had me pushing without pause during crowning, so this was fun stuff. Wish I had had the guts and knowledge to tell him to back the heck off. I wish I could have hired a doula this time around but I’m still going to do my best to stay in control!

[…] 1.Birth Sensations & Protecting The Perineum Through It All: This one gets down to the nuts and bolts of third stage (pushing) and what it feels like. I offer suggestions, tips and explanations on how to push effectively without damaging the perineum. […]

[…] 1.Birth Sensations & Protecting The Perineum Through It All: This one gets down to the nuts and bolts of third stage (pushing) and what it feels like. I offer suggestions, tips and explanations on how to push effectively without damaging the perineum. […]

I am Joy, a happily married mother of two waterbirthed babies. I am a doula and a Lamaze Certified Childbirth Educator, who worked as a midwife's assistant at a freestanding birth center in TX. As of 2015, I'm a full-time nursing student who teaches childbirth classes at Park Ridge Health, The Baby Place, in Hendersonville, NC. I love serving laboring moms and I enjoy teaching birth education. I use this blog to write about it all - my life, my children, and my passion of all things childbirth.